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Discussion Starter · #2 ·
HI
I'll put here some Questions from nbme 4...
13 year old boy is brought to the physician because of a 3 month history of left knee pain that is exacerbated by vigorous exercise. He also has had occasional pain in his right knee. There is no history of trauma. He is at 50th percentile for height and weight. His temperature is 37C(98.6F). Examination shows mild swelling and tenderness of the left tibial tubrcle; range of motion is full

for each patient with knee pain; next step in management

A. Radionuclide bone scan
B. MRI of the affected knee
C. Antiobiotic therapy
D. NSAID therapy
E. Knee immobilization
F. Joint Aspiration
 

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Discussion Starter · #3 ·
13 year old boy is brought to the physician because of a 3 month history of left knee pain that is exacerbated by vigorous exercise. He also has had occasional pain in his right knee. There is no history of trauma. He is at 50th percentile for height and weight. His temperature is 37C(98.6F). Examination shows mild swelling and tenderness of the left tibial tubrcle; range of motion is full

for each patient with knee pain; next step in management

A. Radionuclide bone scan
B. MRI of the affected knee
C. Antiobiotic therapy
D. NSAID therapy
E. Knee immobilization
F. Joint Aspiration
I selected Knee Immobilization, and was wrong.

Is the answer NSAIDs, as most posible???
 

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Discussion Starter · #4 ·
hi

another query:
form 4 section 1 q 17:

17. A 16-year-old boy is brought to the physician because of a 3-day history of right knee pain associated with redness and swelling. There is no history of trauma.he is at the
50th percentile for height and weight. His temperature is 38.6°C (101.5°F). Examination shows ery thema. swelling, and tenderness of the right knee ,and range of motion is limited.
select the most appropriate next step in management:

o A) Radionuclide bone scan
O B) MRI of the affected knee
O C) Antibiotic therapy
O D) Nonsteroidal anti-inflammatory drug therapy
o E) Knee immobilization
O F) Joint aspiration

See that have temperature, it's like septic arthritis
NSAIDs are wrong here

WHat is the answer? to Give antibiotics, or to make joint aspiration first???
 

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Discussion Starter · #5 ·
hi

A 32-year-old woman comes for a follow-up examination 1 week after a Pap smear showed a high-grade squamous intraepithelial lesion. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A ) Repeat Pap smear

B ) Trichloroacetic acid therapy

C ) Colposcopic-directed biopsy

D ) Cone biopsy of the cervix

E ) Cryosurgery of the cervix
 

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Discussion Starter · #6 ·
A 32-year-old woman comes for a follow-up examination 1 week after a Pap smear showed a high-grade squamous intraepithelial lesion. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A ) Repeat Pap smear

B ) Trichloroacetic acid therapy

C ) Colposcopic-directed biopsy

D ) Cone biopsy of the cervix

E ) Cryosurgery of the cervix
Answer is C colposcopic directed biopsy, as confirmatory , to see in deepth...
 

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Discussion Starter · #7 · (Edited)
37. A 47-year-old woman comes to the physician because of difficulty sleeping for 2 months. During this period, she has been awakening at 3 AM and remaining awake worrying about work, even though she is tired. She has unstable angina pectoris and required placement of one coronary artery stent 6 months ago and a second stent 4 months ago. Her chest pain started to recur 1 month ago. and she now has it almost daily. Evaluation shows no organic cause for her recurring chest pain. She works as an attorney for a large firm and reports that she has been given more responsibility during the past year. For the past month, she has not enjoyed her work as much as she previously did. She forces herself to goto work and has difficulty paying attention while she is there. She is a gourmet cook but no longer prepares meals because she does not enjoy the taste of the food. Physical examination shows no abnormalities. On mental status examination, she has a sad and worried mood and a reactive affect. She is alert and oriented to person, place, and time. She states that she frequently becomes despondent, especially when she thinks about her heart disease. Which of the following is the most likely diagnosis?
O A) Adjustment disorder wrong
O B) Dysthymic disorder do not feat here
O C) Generalized anxiety disorder should be more than 6 months
O D) Major depressive disorder**** don't see other symptoms characteristics
O E) Primary insomnia*****?????
 

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Discussion Starter · #8 ·
37. A 47-year-old woman comes to the physician because of difficulty sleeping for 2 months. During this period, she has been awakening at 3 AM and remaining awake worrying about work, even though she is tired. She has unstable angina pectoris and required placement of one coronary artery stent 6 months ago and a second stent 4 months ago. Her chest pain started to recur 1 month ago. and she now has it almost daily. Evaluation shows no organic cause for her recurring chest pain. She works as an attorney for a large firm and reports that she has been given more responsibility during the past year. For the past month, she has not enjoyed her work as much as she previously did. She forces herself to goto work and has difficulty paying attention while she is there. She is a gourmet cook but no longer prepares meals because she does not enjoy the taste of the food. Physical examination shows no abnormalities. On mental status examination, she has a sad and worried mood and a reactive affect. She is alert and oriented to person, place, and time. She states that she frequently becomes despondent, especially when she thinks about her heart disease. Which of the following is the most likely diagnosis?
O A) Adjustment disorder wrong
O B) Dysthymic disorder do not feat here
O C) Generalized anxiety disorder should be more than 6 months
O D) Major depressive disorder**** don't see other symptoms characteristics
O E) Primary insomnia*****?????
Decreased sleep, anxiety, worry, do not cook more because do not see any interest and tasty food, so it's like Major depressive disorder...
 

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Discussion Starter · #9 ·
25 A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive for 2 years She also has had pain with sexual intercourse over the past 6 months She has been otherwise healthy Menarche was at the age of 13 years, and menses have occurred at regular 28-day intervals Her last menstrual period was 1 week ago Her temperature is 37C (986F). pulse is 80mm. respirations are 20/mm, and blood pressure is 120/80mm Hg Abdominal examination shows right lower quadrant tenderness Pelvic examination shows a 5-cm. tender. right adnexal mass Laboratory studies show
Hemoglobin 12 gdL
Leukocyte count 9000mm3
Segmented neutrophils 60%
Bands 5%
Lymphocytes 30%
Monocvtes 5%
Ervthrocyte sedimentation rate 15 rnnti
A urine pregnancy test is negative Urasonography shows a 5-cm nght adnexal mass containing low-level. homogeneous. internal echos A biopsy specimen of the mass is most likely to show which of the following?
O A) Atypical ovarian epithelial cels
o B) Enciometnal glands and stroma
O C) Luteinized granulosa cells
o 0) Myometrium
o E) Squamous cells. cartilage. and bone is wrong because mass is homogeneous******
 

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Discussion Starter · #10 ·
25 A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive for 2 years She also has had pain with sexual intercourse over the past 6 months She has been otherwise healthy Menarche was at the age of 13 years, and menses have occurred at regular 28-day intervals Her last menstrual period was 1 week ago Her temperature is 37C (986F). pulse is 80mm. respirations are 20/mm, and blood pressure is 120/80mm Hg Abdominal examination shows right lower quadrant tenderness Pelvic examination shows a 5-cm. tender. right adnexal mass Laboratory studies show
Hemoglobin 12 gdL
Leukocyte count 9000mm3
Segmented neutrophils 60%
Bands 5%
Lymphocytes 30%
Monocvtes 5%
Ervthrocyte sedimentation rate 15 rnnti
A urine pregnancy test is negative Urasonography shows a 5-cm nght adnexal mass containing low-level. homogeneous. internal echos A biopsy specimen of the mass is most likely to show which of the following?
O A) Atypical ovarian epithelial cels
o B) Enciometnal glands and stroma
O C) Luteinized granulosa cells
o 0) Myometrium
o E) Squamous cells. cartilage. and bone is wrong because mass is homogeneous******
Answer looks to be B
Because have pain with intercouse, patients from that age most likely have Endometrioma that produce pain during intercourse instead of cancer...
 

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Discussion Starter · #11 ·
30. A 17.year-old boy is brought to the emergency department by his parents because they were informed by his school counselor that he wants to commit suicide. Last week, he
broke up with his girlfriend of 2 years, and today he learned that he did not get accepted to his university of choice. On questioning, he says that he is sad and admits that he
had spoken of suicide to a friend but states that he does not want to hurt himself because of religious beliefs “My family would be hurt, too." he states. He has no history of
medical or psychiatric illness and takes no medications He does not smoke cigarettes or drink alcohol Physical examination shows no abnormalities On mental status
examination, he is cooperative and makes good eye contact In addition to recommending outpatient therapy, which of the following is the most appropriate physician
recommendation to this patient's parents?
o A) “Don’t make him go to school until he feels better. He can’t concentrate in his present state of mind”
O B) "Let him rest and spend time alone. He needs space to think.”
o C) "Make sure he does not have access to guns”
o D) "Perhaps you should invite his ex-girlfriend over to cheer him up”
0 E) "Pray with him daily. Religion is an important protective factor”
 

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Discussion Starter · #12 ·
30. A 17.year-old boy is brought to the emergency department by his parents because they were informed by his school counselor that he wants to commit suicide. Last week, he
broke up with his girlfriend of 2 years, and today he learned that he did not get accepted to his university of choice. On questioning, he says that he is sad and admits that he
had spoken of suicide to a friend but states that he does not want to hurt himself because of religious beliefs “My family would be hurt, too." he states. He has no history of
medical or psychiatric illness and takes no medications He does not smoke cigarettes or drink alcohol Physical examination shows no abnormalities On mental status
examination, he is cooperative and makes good eye contact In addition to recommending outpatient therapy, which of the following is the most appropriate physician
recommendation to this patient's parents?
o A) “Don’t make him go to school until he feels better. He can’t concentrate in his present state of mind”
O B) "Let him rest and spend time alone. He needs space to think.”
o C) "Make sure he does not have access to guns”
o D) "Perhaps you should invite his ex-girlfriend over to cheer him up”
0 E) "Pray with him daily. Religion is an important protective factor”
This is the why from UpTodate: Outpatient therapy is usually the best option for lower risk individuals (eg, patients who are medically stable and are not imminently suicidal) [19,25]. Outpatient therapy requires the involvement of the family and their willingness to stay with the patient indefinitely [2,12,13]. All lethal means of suicide, particularly firearms and medications, should be made unavailable to the patient. The acute crises that precipitated the event must be addressed and attempts made to resolve them. The patient and parents should be warned about the dangerous disinhibiting effects of alcohol and other drugs [2]. Psychiatric follow-up must be secured within 48 hours and the patient and family members should be instructed to return to the emergency department if things are not going well

Medication, and guns or any subject that can serve as suicide to protect and take fairly from patient...
 

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Discussion Starter · #13 ·
A cohort study is conducted to assess the relationship between oral contraceptive use and risk of breast cancer. PArticipants are chosen from closed panel health maintainance organizaion(HMO) and include 530 women between 30 and 40 years of age with no gynaecologic disease. Each participant is asked to complete a questionnaire about her use of oral contraceptive. twenty years later 40% of the participants are enrolled in the same HMO . Of the 100 women who remained with the HMO and continued to use an OCP, 12 patients had histologically confirmed breast cancer compared to 4 patients among the women who did not use an OCP . Which of the following features of the study is most likely to affect its validity?
a. Differential follow up
b. Lead time Bias
c. Misclassification of exposure wroooooooooooong
d. Misclassification of outcome wrooooooooooong
e. Recall bias
 

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Discussion Starter · #14 ·
A cohort study is conducted to assess the relationship between oral contraceptive use and risk of breast cancer. PArticipants are chosen from closed panel health maintainance organizaion(HMO) and include 530 women between 30 and 40 years of age with no gynaecologic disease. Each participant is asked to complete a questionnaire about her use of oral contraceptive. twenty years later 40% of the participants are enrolled in the same HMO . Of the 100 women who remained with the HMO and continued to use an OCP, 12 patients had histologically confirmed breast cancer compared to 4 patients among the women who did not use an OCP . Which of the following features of the study is most likely to affect its validity?
a. Differential follow up
b. Lead time Bias
c. Misclassification of exposure wroooooooooooong
d. Misclassification of outcome wrooooooooooong
e. Recall bias
Answer is A. I got it right in online nbme. many reasons: out of 530 only 100 remained in the study. this "loss to follow up" creates huge selection bias problem. so differential followup here means that people of different exposures are followed differentially distorting the results.

http://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_Bias/EP713_Bias_print.html

Preventing Loss to Follow-up

LightBulb.jpg

The only way to prevent bias from loss to follow-up is to maintain high follow up rates (>80%). This can be achieved by:

Enrolling motivated subjects
Using subjects who are easy to track
Making questionnaires as easy to complete as possible
Maintaining the interest of participants and making them feel that the study is important
Providing incentives
 

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Discussion Starter · #15 ·
10. A previously healthy 57 yo man complains of impotence for 1 year. Examination shows a bronze- colored skin. His serum ferritin is 4050. The patient is at increased risk for the following complication?

A. Hepatocellular carcinoma
B. Interstitial lung disease
C. MI
D. Progressive pancytopenia
E. Renal Failure
 

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Discussion Starter · #16 ·
10. A previously healthy 57 yo man complains of impotence for 1 year. Examination shows a bronze- colored skin. His serum ferritin is 4050. The patient is at increased risk for the following complication?

A. Hepatocellular carcinoma
B. Interstitial lung disease wrong
C. MI
D. Progressive pancytopenia not
E. Renal Failure
not

I think answer is MI because in hemochromatosis, patients develop constrictive cardiomyopathy.
and Cirrhosis if not corelated Iron level with phlebotomy , but not mostly Hepatocellular carcinoma...
 

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Discussion Starter · #17 ·
7. A 27-year-old woman is brought to the physician because ot a 3day history of visual loss and aching discomfort in her right eye. Three years ago,she had vertigo,diplopia and an ataxic gait and was diagnosed with an inner ear infection Her symptoms resolved within 1 month without treatment. Examination shows markedly diminished visual acuity on the right: the peripheral visual fields are full to confrontation. Color vision is decreased in the right eye. The right eye does not react to light but has a normal consensual response. Fundoscopic examination shows no abnormalities. She has an ataxic gait. Babinski sign is present bilaterally. Which of the following is the most appropriate next step in diagnosis?
o A) Carotid ultrasonography
o B) Electromyography
o C) Visual evoked potentials
o D) CT scan of the head with contrast
o E) MRI of the brain with contrast
 

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Discussion Starter · #18 ·
7. A 27-year-old woman is brought to the physician because ot a 3day history of visual loss and aching discomfort in her right eye. Three years ago,she had vertigo,diplopia and an ataxic gait and was diagnosed with an inner ear infection Her symptoms resolved within 1 month without treatment. Examination shows markedly diminished visual acuity on the right: the peripheral visual fields are full to confrontation. Color vision is decreased in the right eye. The right eye does not react to light but has a normal consensual response. Fundoscopic examination shows no abnormalities. She has an ataxic gait. Babinski sign is present bilaterally. Which of the following is the most appropriate next step in diagnosis?
o A) Carotid ultrasonography
o B) Electromyography
o C) Visual evoked potentials
o D) CT scan of the head with contrast
o E) MRI of the brain with contrast
Ataxic gait plus symptoms of optic neuritis

MRI is most accurate test for Multiple sclerosis...
 

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Discussion Starter · #19 ·
10. A 13-year-old boy is brought to the physician because of a 2-week history of left hip pain with an associated limp. He has had no redness or swelling ofthe left leg or hip.
There is no history of trauma or musculoskeletal problems. He is at the 50th percentile for height and above the 95th percentile forweight. Sexual development is Tanner
stage 2. His temperature is 3?.5°C (99.5°F). pulse is 80/min. respirations are l2/min. and blood pressure is l20/75 mm Hg. He holds his left lower extremity in slight external
rotation and hip flexion at rest. Internal rotation and abduction ofthe left hip are decreased. Range of motion ofthe knees and ankles is full. and there is no swelling or
erythema ofthe knee and ankle joints. He walks with a limp and is unable to bear his full weight on the left. Which ofthe following is the most likely underlying cause of this
patient's condition'?
O A) Acute inflammatory reaction ofthe synovial lining ofthe hip joint
O B) Avascular necrosis of proximal femur
O C) Bacterial infection ofthe hip joint
O D) Disruption ofthe femoral head epiphyseal plate
O E) Inflammation ofthe ligaments ofthe hip joint
 

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Discussion Starter · #20 ·
10. A 13-year-old boy is brought to the physician because of a 2-week history of left hip pain with an associated limp. He has had no redness or swelling ofthe left leg or hip.
There is no history of trauma or musculoskeletal problems. He is at the 50th percentile for height and above the 95th percentile forweight. Sexual development is Tanner
stage 2. His temperature is 3?.5°C (99.5°F). pulse is 80/min. respirations are l2/min. and blood pressure is l20/75 mm Hg. He holds his left lower extremity in slight external
rotation and hip flexion at rest. Internal rotation and abduction ofthe left hip are decreased. Range of motion ofthe knees and ankles is full. and there is no swelling or
erythema ofthe knee and ankle joints. He walks with a limp and is unable to bear his full weight on the left. Which ofthe following is the most likely underlying cause of this
patient's condition'?
O A) Acute inflammatory reaction ofthe synovial lining ofthe hip joint
O B) Avascular necrosis of proximal femur
O C) Bacterial infection ofthe hip joint
O D) Disruption ofthe femoral head epiphyseal plate
O E) Inflammation ofthe ligaments ofthe hip joint
Adolescent with 95 percentile of weight, that signify is overweight, obese, externaly rotated foot,mostly going to answer D
DIsruption of the femoral head epiphyseal plate.
 
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